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Nurse Practitioners Going Solo

From running a clinic to launching a private practice, advanced practice nurses are seizing new opportunities

When Debbie Palaski first became a nurse practitioner 25 years ago, she never imagined how quickly the profession would evolve. Over the course of her career, the advanced practice role has become much more physician-collaborative and much less physician-dependent, with opportunities emerging in areas where quality care is needed the most.

“Time has blown by,” she says, “and in a blink of an eye, the profession has changed and grown exponentially.”

Retail Clinics

For the last seven years, Debbie Palaski, RN, BSN, MN, FNP, PNP, has worked at MinuteClinic in Los Angeles, a walk-in medical clinic located inside select CVS/pharmacy stores. This setting, known as a retail clinic, provides care to a variety of patients from the community, including those without health insurance.

“Not only am I doing what I love, but I am once again a pioneer of sorts: a nurse practitioner and manager in the retail healthcare arena,” says Palaski, who is now MinuteClinic’s state practice manager. “This has put me right in the middle of some amazing changes, as we provide access to quality healthcare to so many who may otherwise not know the way.”

Palaski treats acute and chronic health ailments following evidence-based guidelines and standardized procedures. The clinic’s medical directors, who are M.D.s, are available for consultation at any hour, as needed or when changes to the treatment regime are required. The physicians also present continuing education topics to the NPs, communicating on a peer level.

“I don’t even have a sense they are supervising me; rather, that we are collaborating and working as a team to provide the best and most appropriate patient care,” Palaski says. “I feel my experience and support system here at MinuteClinic allows the most independent practice opportunity and the need for a supervising physician is redundant.”

Home Health

Monique Gutierrez, MSN, GNP, CNS, WCC (photo above left), a geriatric nurse practitioner and clinical manager for CareMore House Call and Palliative Care Program in Los Angeles County, was inspired to become a NP by her desire to make a difference for patients and move the nursing profession forward.

“The best thing about being an NP is the freedom to make patient care plans and decisions with patients about their care on my own license without waiting for permission to follow through with a plan of care,” she says.

Gutierrez works on call, conducting in-home assessments such as physical examinations, home safety evaluations and end-of-life consultations for high-risk or complex patients, many of them elderly. Between visits, she returns patient calls, refills medications and provides patient updates to case managers and primary physicians.

“I used to feel stressed out as an RN, needing a pain medication stat or an X-ray order right away, but having to wait for a physician’s order to carry it out,” Gutierrez says. “Now, I can just write the prescription and order the X-ray.”

She also has a physician available to contact by phone or email if needed. “Once a month, I meet with the house call physician and other house call NPs/LVNs in person to discuss any complicated cases,” she says. “We brainstorm and support one another to develop an appropriate care plan for challenging cases we come across on the field.”

Occupational Health

Janette Matthess, RN, MSN, FNP-C, is an occupational health nurse practitioner at a pharmaceutical research facility in Southern California. She treats occupational injuries and illnesses and performs health surveillance for employees who handle chemicals, work with animals or work in potentially hazardous areas. She also provides travel medicine, immunizations, flu shots, lab draws and urgent care treatment.

“In California, I must work under the supervision of a medical doctor, but I have full autonomy to work within my scope of practice, which has been developed through collaboration between the medical director and me,” Matthess explains. “Rarely do I interact with the medical director, who is my supervisor, but he is always available, as required by California law, via the phone, text or email if any issues or questions arise.”

Matthess, who also works part-time in a refugee clinic, learned the value of collaboration among clinicians after helping to care for her mother, who has Parkinson’s disease. “My goal is to ensure I always have good communication with my patients and the other providers so no one has a lapse in continuity of care.”

Recently, one of her patients took her wellness advice and managed to end his pre-diabetic status, normalizing his glucose levels and blood pressure, reducing his cholesterol and losing 10 pounds. “It made my day and told me I really can make a difference in my patients’ lives,” Matthess says.

Private Practice

Laurie Love, MSN, RN, FNP-BC, has the most autonomous role of all: She owns her own private practice. She started her company, Compassionate Healthcare Associates, in Santa Clarita in 2010 after leaving a practice partnership she co-owned with a fellow NP.

“We don’t want to have that dictation from a larger entity, such as an organization that provides healthcare that has quotas for the number of patients to be seen,” says Love, who is also a clinical faculty member at UCLA School of Nursing. “I didn’t want to provide care that way.”

Love typically treats 12 to 15 patients a day and believes that good healthcare is “not just about taking a pill.” She follows her motto, “protect health, prevent illness,” providing lots of education and spending up to an hour with each patient to establish a therapeutic relationship.

Love communicates with a collaborating physician to co-manage care as needed. For example, she may send him a text message to get his thoughts on an abnormal lab result or a referral to the emergency department. The physician also meets with her on site every few months. Love has dedicated patients who still come to see her from her previous work in Simi Valley and also finds new clients via a regular health column she writes for a local periodical.

Currently, Compassionate Healthcare Associates consists only of Love and two medical assistants, but her vision is to expand into a comprehensive, holistic practice with several NP specialists. “Right now, it’s little old me trying to survive, but many other NPs have aspired to do work like this,” she says. “I believe that with a strong educational background, many years of practice, a lot of motivation, a big heart and a desire to help others, any NP can do what I do.”

Debbie Palaski, Monica Gutierrez, Janette Matthess and Laurie Love all exemplify the value a NP can offer — not as a physician apprentice or replacement, but as an autonomous provider working in collaboration with a physician to provide convenient, well-coordinated, thoughtful and effective care.

“The American consumer and governmental bodies are accepting the nurse practitioner as a dependable and acceptable alternative provider of healthcare,” Palaski says. “I suppose there will always be those steeped in the traditional healthcare model, but for the rest of us, the future is bright and one where physicians and NPs work together to meet the needs of those seeking a dependable source of healthcare.”

Daria Waszak, RN, MSN, CEN, COHN-S, is a Long Beach native and SDSU and UCLA alumna. She has a myriad of clinical and administrative experience over the last 19 years and is currently pursuing a DNP degree in nursing leadership.